Wiki Deciding on 99213 over 99212

[HeatherrLaw]

Hello,
I have a case where patient presents with cough, congestion, nasal congestion, shortness of breath and some pain swallowing. Provider orders three tests Covid, flu and strep. Assigned Acute respiratory respiratory infection J22, Cough R05.9, Nasal congestion R09.81 and Throat pain R07.0. Test results discussed. Would that be 99213 along with tests.
Thank you.

 

[willicoxj]

For an established patient office visit with Low complexity of problem (acute, uncomplicated illness), Moderate complexity of data (ordering 3 unique tests), and Minimal risk of management use 99213.

 

[HeatherrLaw]

For an established patient office visit with Low complexity of problem (acute, uncomplicated illness), Moderate complexity of data (ordering 3 unique tests), and Minimal risk of management use 99213.

Thank you for your response. Would this also be true for two tests (flu and covid)? Also, what if the time requirement is not met? Do you need both the MDM and the time of 20-29 mins to be able to bill for this code?

 

[sls314]

Thank you for your response. Would this also be true for two tests (flu and covid)? Also, what if the time requirement is not met? Do you need both the MDM and the time of 20-29 mins to be able to bill for this code?

E/M levels are selected on either MDM or time - it does not have to meet both. You can choose whichever is most advantageous to the provider for the encounter.

 

[HeatherrLaw]

E/M levels are selected on either MDM or time - it does not have to meet both. You can choose whichever is most advantageous to the provider for the encounter.

That is great information. Thank you. I have a provider who consistently codes 99212 even though one - three tests were ordered and resulted in the progress note. example Acute uncomplicated illness (sore throat, pain with swallowing, pain in ears) CPT codes 99212, 87426 and 87804, 87880. All the research I have done and discussion seems like that should be 99213 but as a newer coder I want to verify. Thank you in advance.

 

[HeatherrLaw]

For an established patient office visit with Low complexity of problem (acute, uncomplicated illness), Moderate complexity of data (ordering 3 unique tests), and Minimal risk of management use 99213.

Would I still be able to list the CPTs for the tests performed on the claim? I have read some threads that state if you are using the tests to count towards office visit you cannot list separately? Is that correct? For instance in this claim I asked about it would be 99213 , 87426, 87804.

 

[csperoni]

Would I still be able to list the CPTs for the tests performed on the claim? I have read some threads that state if you are using the tests to count towards office visit you cannot list separately? Is that correct? For instance in this claim I asked about it would be 99213 , 87426, 87804.

I think you may be confusing 2 different guidelines.
1) If you perform a service that has a PROFESSIONAL component you bill for, you may not count that test toward your data element for E&M. You would still bill for the test you performed.
2) These labs are results only (NO professional component), so you may count them toward your data element for E&M
From AMA:
►The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.◄